Project Name: ___________________________________________

Location/Area: __________________________________________

Date: [//_____]

Reporter Details

Name of Reporter: _______________________________________

Role/Position: __________________________________________

Contact Information: _____________________________________

Hazard Details

Time of Observation: _____________________________________

Specific Location of Hazard: ______________________________

Type of Hazard: (e.g., Slip and Trip, Electrical, Chemical, Mechanical, etc.)


Description of the Hazard:




Immediate Actions Taken (if any):